MammaPrint Breast Cancer

1

Name and Surname

First Name

Last Name

2

Have you been diagnosed with early stage breast cancer?

3

Would you like to know if you're at risk for recurrence?

4

Would you like to avoid the use of chemotherapy?

5

What is the tumor size?

Less than 1cm

Between 1cm and 5cm

Greater than 5cm

6

What is the cancer grade?

1

2

3

Unknown

7

The lymph node status?

1 Positive

2 Positive

3 Positive

Negative

8

Estrogen receptor status?

Positive

Negative

9

Progesterone receptor status?

Positive

Negative

10

Histology subtype?

Ductal Carcinoma

Lobular Carcinoma

Mammary Carcinoma

Other

11

HER-2 / FISH / SISH status?

Positive

Negative

12

May we share this information with a genetic counselor?

Yes

No

13

Contact Number

Area Code

Phone Number

14

Your Email* This field is required.